Prof. Dr. Shyam P Lohani

It is up to us to make our life healthier by adhering to better diet plan, regular moderate level of exercise, bettering air quality, quitting smoking, and stopping dangerous use of alcohol. Having talked about lifestyle modification to decrease chances of developing or delaying many of the non-communicable diseases (NCD), the rate of incidence of diabetes is growing at fast pace, especially in low and middle-income countries. One of the upcoming issues which have become a significant contributor to NCDs related mortality throughout the world is diabetes mellitus.

Situation
It has been estimated that the prevalence of diabetes is 8.5 per cent (422 million) in 2014 up from 4.7 per cent (108 million) in 1980 (WHO, 2018). Worldwide, around 1.6 million deaths were due to diabetes in 2016 and an additional 2.2 million deaths were related to high blood sugar in 2012 (WHO, 2018). The exact burden of diabetes in Nepal is not known but has been estimated at 9.1 per cent among Nepali population in which male outnumbered female.
Diabetes is the chronic condition in which either the pancreases do not produce sufficient hormone called insulin or the body cannot effectively utilise the insulin produced. The raised blood sugar or hyperglycemia is the result of uncontrolled blood sugar that in turn may cause effects to many of the vital organs such as heart, kidney, and nerves. There are different types of diabetes such as Type I diabetes, Type II diabetes, gestational diabetes, and impaired glucose tolerance. The type I diabetes is characterised by a deficiency in the production of insulin and requires insulin therapy. The onset of the disease is in young age and symptoms include polyuria (frequent urination), polydipsia (increased thirst), polyphagia (increased hunger), weight loss, vision changes, and fatigue. The onset of the disease is sudden and the cause of this form of diabetes is still not known.
Type II diabetes is usually due to the body’s inability to effectively utilise insulin. The symptoms are similar to type I diabetes. The prevalence of this form of diabetes is more than type I diabetes and mainly the result of excess body weight and physical inactivity. Type II diabetes is often diagnosed several years after the onset of disease and many patients will already have several complications. Gestational diabetes occurs during pregnancy and women with this form of diabetes are at increased risk of complications during pregnancy and delivery. The mother and children born are at increased risk of developing type II diabetes in the future. Impaired glucose tolerance or impaired fasting glycemia is the intermediate condition between normality and diabetes. They are at higher risk of developing type II diabetes in the future.
Diabetes is implicated for higher incidences of heart attacks, stroke, kidney disease, blindness, and lower limb amputation. The persistence of high blood sugar damages blood vessels and nerves that control blood vessels and heart. The people with either type of diabetes are two to four times more likely to have heart attacks and stroke (WebMed, n.d.). It has been shown that about 65 per cent of people with diabetes die from some sort of heart disease or stroke. There is decrease in the blood flow to the feet that causes damage to the nerve (peripheral neuropathy) in the foot which increases chances of foot ulcer, infection and lower limb amputation. The sustained high blood sugar damages the small blood vessels to the retina and causes diabetic retinopathy leading to loss of vision. According to WHO (2018), 2.6 per cent of global blindness is due to diabetic retinopathy. The persistent high blood sugar level may lead to diabetic nephropathy that eventually causes kidney failure. About 20-30 per cent of people with diabetes may develop diabetic nephropathy although all people with diabetic nephropathy will not develop kidney failure.
Although diabetes is a chronic disease, the people with this disease can have a good quality of life often with lifestyle modification or lifestyle modification plus medication (either oral antidiabetic drugs or insulin). Until now, type I diabetes cannot be prevented and the environmental cause that destroys the insulin-producing cells in the pancreases is still not known. However, type II diabetes can be prevented or can be delayed in its onset by adopting healthy food habits, increasing physical activities and changing sedentary behaviour. In our country, the prevalence of diabetes in rural areas is far less than the urban areas and this has affected almost every household in the urban areas.

Guidelines
The most important task is that the government should formulate guidelines and devise strategies for reducing pre-mature death by one third as set by Sustainable Development Goals (SDGs). All the government and non-governmental organisations should be encouraged to initiate nationwide awareness programmes for the prevention of NCDs. The large scale screening for diabetes should cover the wider population. The availability of the oral antidiabetic drug is limited to only one drug, i.e. metformin in the free drug scheme of the government which needs to be expanded. The prices of other oral antidiabetic drugs and insulin should be controlled and made affordable to all diabetic people. The country should strive to prevent or delay in the onset of diabetes as well as create awareness among the people who are already diabetic to seek for the better quality of life by lifestyle modifications. After all, healthy people and people who have a better quality of life will contribute to the economic health of the country.

(Prof. Lohani is the Clinical Director of the Nepal Drug and Poison Information Centre. He can be reached at lohanis@gmail.com)